Introduction
Over the past few decades, a significant number of clinical and physical therapy studies have been conducted in order to determine some of the major causes of back pain. As a result of these numerous studies, most researchers and scholars in clinical and physical therapy now generally agree that sacroiliac joint (SIJ) still remains the leading cause of lower back pain. However, Freburger and Riddle (2001) contend that the issue still remains controversial (Freburger & Riddle 2001). On the other hand, it is widely believed that the SIJ has the capability of causing pain around the back region, lower extremity region, groin and buttocks. There is ample evidence in literature on sacroiliac joint to support the claim that SIJ can cause back pain since past research suggests that the stimulation of the sacroiliac joints and lumbar zygapophyseal can evoke lower extremity, buttock and back symptoms (Laslett et al. 2003, p. 89). Nonetheless, the subject still remains controversial since different researchers have different views and opinions as regards the subject. In addition, there lacks a general agreement in relation to the diagnostics tests carried out in the past on the same subject as well as their reliability and validity.
Sacroiliac joint (SIJ) dysfunction is a clinical term used to “describe pain in or around the region of the joint that is presumed to be due to biomechanical disorders of the joint” (Freburger & Riddle 2001, p. 1135). Based on the above definition, one gets the impression that SIJ describes the pain that could be as a result of subluxation, fixation, malaligmnet, and hypomobility. The major problem faced while treating SIJ dysfunction is that SIJ is internally located around the hip and the pelvic region and it may be confused with other causes of back pain. Some of the noted causes of SIJ dysfunction include arthritis pregnancy, trauma from accidents, and SIJ infection which is a rare cause.
The objective of the essay is to undertake a critical literature review as regards the techniques for sacroiliac joint dysfunction. Such a critical literature review is intended to determine the importance of scientific enquiry and evidence based practice for advancing the field of physical therapy.
Critical review of the literature
Importance of EBP and scientific enquiry
Different procedures and tests have thus far been carried out and applied by physical therapists in evaluating patients assumed to have dysfunction in the SIJ region. Some of these methods have been applied to assess “the anatomical symmetry of bony landmarks on the right and left innominates” (Freburger & Riddle 1999). As a result, anatomical symmetry has been applied in determining whether the left and right innominates are symmetrical or asymmetrical. Several researchers and authors claim that asymmetry on this particular finding could be an indication of SIJ dysfunction and misalignment (Freburger & Riddle 1999). Based on existing research, the field of physical therapy has undergone a major transformation drawing from the research findings of evidence based practice and scientific enquiry. As noted by Freburger and Riddle (2001), many therapists in the field of physical therapy carry out examinations with a view to checking the presence of SIJ dysfunction around the SIJ region. In addition, Freburger and Riddle (2001) report of a research that had been carried out in which 75% of the therapists affirmed that they had ended up subjecting their patients who had complained of experiencing low back pain to screening procedures.
Numerous studies have been conducted in the past few decades with the objective of establishing their validity and reliability properties. Using developed diagnostic test acts as the best standard for determining SIJ dysfunction point of origin. As a result of the research findings from these studies, it is becoming increasingly easier to diagnose patients suffering from lower back pain (LBP) (Freburger & Riddle 2001). By assessing the pain originating from the test, an examiner is able to determine whether the pain originates from the SIJ. The use of anesthetic blocks coupled with a needle inserted deep in the SIJ ensures that the validity of the test is examined.
According to Freburger and Riddle (2001) these past researches has been used to create evidence based practice (EBP) basis from where therapists can carry out their practices. As illustrated by Salmond (2007), evidence based practice is an important decision making approach which is applied in clinical practices with the objective of enhancing best patient results. In the context of physical therapy, existing evidence plays an integral role in ensuring that best outcomes are derived while dealing with SIJ dysfunction. As illustrated in the preceding paragraphs, past research has been carried out on the subject matter where validity and reliability measures have been analysed to ensure that patients get the best treatment available. As a result, therapists have been able to diagnose and examine SIJ since according to Laslett et al. (2005, p. 207), past research has shown that physical examination cannot be used as a method in the diagnosis of SIJ pathology. Subsequently, therapists are able to differentiate between LBP resulting from other causes and pain resulting from SIJ dysfunction, in effect enhancing better diagnostics and treatment of SIJ dysfunction in patients.
Techniques applied in SIJ dysfunction, assumptions and appropriateness
A common technique applied by physical therapists in assessing SIJ alignment is the assessment and the palpation of anatomical symmetry. Freburger and Riddle (2001) have also indicated that another test entails determining bony landmarks movements as regards SIJ. Thereafter, the therapist has to apply force to SIJ. This is intended to produce pain. The three methods are used by therapists with the aid of the patient’s medical records. In addition, therapists use the description of pain given by patients. Therefore, the three methods identified above lack any form of instrumentation and hence the advocacy for EBP. The limitation of these methods is that they have no scientific basis and as such, wrong therapy may be carried out given the source of pain is not articulately located. A study conducted in Australia by Peace and Fryer (2004, p.1) showed that most the participants used these three methods to test and diagnose SIJ dysfunction. Out of the 168 osteopaths used in the study, 14 percent responded having not used the pain provocation method. In their conclusion, Peace and Fryer (2004, p.1) acknowledged that although there was high usage level of pain provocation, most of the osteopaths used Mitchell’s Model, pain provocation and motion tests were used to support the diagnostic procedures. Lastly, majority of the participants used pain provocation tests although there is no osteopathic text advocates for that.
Some methods such as pain provocation technique has been criticized because the results are usually false-positive. As noted by Laslett (2008), the pain provocation tests give more positive results if carried on LBP patients compared to the accepted SIJ pain prevalence. The implication made is that because of the false-positive results, multiple tests are required to give a more positive outcome. This makes the method less perfect since it is time consuming and may take more time before an agreed measure and test are achieved. In addition, there are different causes of LBP and offering SIJ tests using this method may not be appropriate. However, to counter this drawback, clinical reasoning process (CPR) has been recommended to act as a prediction rule which could be used to identify the portion of patients with pain resulting from SIJ (Laslett 2008). Through the use of SIJCPR, therapists would be in a position to determine SIJ dysfunction/pain on normal patients which is supposed to be over 70% on normal patients, while on pregnant mothers to at least 90 percent.
In the modern physical therapy, the commonly applied standard is the RSA (roentgen stereo-photogrammetric analysis) and “fluoroscopically guided anesthetic blocks” (Cibulka 2001). Different researchers have come to an agreement that anesthetic block is the current available standard used in the identification of SIJ region while, the RSA is the available standard used to measure SJI movement (Freburger & Riddle 2001; Slipman et al. 2001; Cibulka 2001). Although these two methods have been criticized by opponents such as Michael T Cibulka, proponents such as Janet K Freburger and Daniel L Riddle are quick to refute the claims on grounds that past research have indeed supported the use of RSA and anesthetic blocks.
Most of the research conducted on SIJ dysfunction in either of the above mentioned methods share similarities with the sample data used in the study. For example, according to Freburger and Riddle (1999), Potter and Rothstein in their study used participants, who had shown symptoms close to sacroiliac joint region, another study by to Freburger and Riddle (2001) used six past research materials which had used patients showing characteristics associated with SIJ dysfunction. In addition, all the patients used in these studies showed a variety of traits which are occasionally witnessed by practicing physical therapists. Furthermore Tullberg et al. (1998) used patients who had reported symptoms related to SIJ dysfunction.
Critical review
Different researchers have raised different views on the issue of SIJ dysfunction. Some believe that LBP can be as a result of SIJ dysfunction while others refute the claims (Fritz et al. 2008, p.1718). Others like
Huijbregts (n.d) acknowledge that the issue has created confusion among physical therapists. However, the author is keen to illustrate further that clinical reasoning procedure has been valuable and reliable in proving that more tests on the provocation procedure are required. Laslett et al. (2003) on the other hand, has noted that conclusions of past research show that “there is no composite of symptoms or clinical signs that enable the clinician to identify pain originating from the SIJ” (p.89) and as a result, the only agreed diagnostic tool is the use of fluoroscopically-guided contrast enhanced anesthetic injection. Other studies have shown low sensitivity in using symptoms to determine whether a patient was suffering from SIJ dysfunction and therefore, the results cannot be depended upon. By using McKenzie evaluation, Laslett et al. (2003, p.90) noted that there is possibility of detecting pain especially LBP. Lastly, most of the examiners who have used the McKenzie evaluation have been able to agree on the model for its applicability in testing and diagnosing SIJ dysfunction.
In a study carried by Tullberg et al. (1998), the researchers concluded that positional tests are not reliable and the results cannot be used to prove or disprove whether SIJ manipulation can result to SIJ dysfunction. This is because in their study, SIJ manipulation normalized various clinical tests carried and did not result to SIJ position alteration. Slipman et al. (2000) note that SIJ can be a true source of LBP based on a research that was carried in 1905 by Osgood and Goldwaith who are the pioneers of the subject. In addition, other cases carried by Albee in 1909 proved positive on the same. However, the difference between these researches and modern ones is that cadavers instead of living human were used which makes it hard to support.
To show the false-positive tests, Laslett et al. (2005) undertook a research which showed that pain provocation tests although advocated for, have mixed results. In addition, diagnostic injection showed positive results on patients who had SIJ provocation tests compared to those who had negative injections. The positive results ranged from 29 percent to 50 percent which is commendable percentage. The conclusion made was that SIJ provocation tests proved to have a high diagnostic utility (Laslett et al. 2005). This conclusion has been shared by Freburger and Riddle (2001) who encourage the use of pain provocation tests supported by the pain description given by patients as a means of identifying SIJ dysfunction in the SIJ region. In addition, Laslett (2008) acknowledges that more than 3 tests need to be carried to increase the degree of reliability and validity. As a result, physical therapists are advised to adopt EBP while carrying examination on issues related to SIJ. This is because less scientific data and EBP exist in support of the use of movement of symmetry tests (Laslett 2008).
Conclusion
Based on the literature review and evaluation above, the association between SIJ and lower back pain is not agreed upon because of the associated symptoms. As noted earlier, there are many causes of lower back pain which are also related to SIJ dysfunction. The application of scientific research and evidence based practice is important in physical therapy as it helps in determining major cause of SIJ as well as providing diagnostic evidence and supports which is necessary in deriving positive results. Furthermore, physical therapists would be in a better position to know lower back pain resulting from SJI which would prompt better diagnostics and treatment of SIJ dysfunction in patients. The available research is supportive to physical therapists. Among the three commonly applied methods, the pain provocation on the SIJ is more preferred although CPR needs to support it. Nonetheless, the approach which has low level of sensitivity requires CPR to increase sensitivity level when more than 3 tests are carried to ascertain the positive outcome of pain provocation. Physical therapists and osteopaths are advised to use the pain provocation approach because research based evidence has proven the reliability and validity of the technique. The symmetrical approach or alignment test on the other hand is not advocated for although it is commonly used. This is because there is little evidence to support its sensitivity when applied.
Reference List
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